今日の臨床サポート

便秘症

著者: 松橋信行 NTT東日本関東病院 消化器内科

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正/監修レビュー済:2021/01/07
参考ガイドライン:
  1. 日本消化器病学会関連研究会 慢性便秘の診断・治療研究会:慢性便秘症診療ガイドライン2017
患者向け説明資料

概要・推奨   

  1. 高繊維食は慢性便秘症の排便状況を改善させるとする報告がある(推奨度2)。
  1. プロバイオティクスは慢性便秘症に有効である可能性がある(推奨度2)。
  1. 浸透圧性下剤は慢性便秘症に有効である(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松橋信行 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行い、診療ガイドライン掲載の便秘問診票を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 便秘症とは、本来体外に排出すべき糞便を十分量かつ快適に排出できない状態をいう。
  1. 便秘患者は非常に多く、世界中の成人の14%に慢性の特発性便秘を認める。
  1. 女性のほうが多く、65歳以上でより一般的で、実際の排便頻度と関係なく、加齢とともに便秘の訴えが増える。
  1. 原因疾患は多岐にわたる。他に明らかな原因のない特発性、器質性、他の全身性疾患に伴う症候性、薬剤性がある。
 
器質性、薬剤性、症候性の便秘の原因

器質性の便秘の原因として表に示した疾患が考えられる。急性発症や、発熱、嘔気、嘔吐、体重減少、貧血、血便、下血などの症状を有したり、50歳以上の場合は、これらを疑って適宜検査を行う。
 
参考文献:MD Consult, p263, CHAPTER 18 Constipation, Elsevier Inc., 2012

出典

img1:  著者提供
 
 
 
予後:
  1. 機能性の便秘のみで生命に関わることはないが、悪化すると肛門部の痛みや腹痛、嘔気や嘔吐が出現し、QOLを損ねる。まれに腸穿孔を合併することもある。
  1. 治療に反応することが多いが、排便が薬剤依存性になることもある。
問診・診察のポイント  
  1. RomeIV基準では、半年以上前から症状があり最近少なくとも3カ月間は下記の症状を満たす患者群を「機能性便秘」と呼ぶ。診断基準を確認するため、以下のことを問診する。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: R E Tagart
雑誌名: Dis Colon Rectum. 1966 Nov-Dec;9(6):449-52.
Abstract/Text
PMID 5926158  Dis Colon Rectum. 1966 Nov-Dec;9(6):449-52.
著者: B Sturtzel, C Mikulits, C Gisinger, I Elmadfa
雑誌名: J Nutr Health Aging. 2009 Feb;13(2):136-9.
Abstract/Text INTRODUCTION: Constipation is a common problem in the elderly population, especially in geriatric wards. Laxatives are the most preferred solution but current studies link constipation and laxative use to weight-loss and malnutrition in nursing homes. Dietary fibers also affect stool weight and transit time. So, oat-bran effectiveness in reducing the need for bowel medication and weight-loss for geriatric care patients was examined in a geriatric hospital.
AIM: To determine whether the addition of oat-bran to common oral diet can reduce the use of laxatives and improve the wellbeing and bodyweight of the inhabitants of a long-term-care facility.
METHODS: The study was designed as a controlled blind intervention trial among 30 frail inhabitants of a geriatric hospital aged 57-100 years with laxative use. Including criteria were: oral food intake and laxatives as therapy and excluding criteria were: parenteral and enteral feeding, surgeries in the gastro- intestinal tract, drugs that shorten or lengthen the passage through the gut, risk of aspiration, swallowing troubles. An intervention and a control group were formed. 15 of them received 7-8 g oat-bran/d for 12 weeks (fiber group) mixed up in the daily common diet of the ward and 15 served as control (control group).
DATA COLLECTION: Bodyweight was taken at baseline, after 6 weeks and at the end of the supplementation. Data on laxative use, stool frequency and the eating habits of the elderly were recorded.
RESULTS: Laxatives were successfully discontinued by 59% (p < 0.001) in the fiber-group; in the control-group there was an increase of 8% (p=0.218). Bodyweight remained constant in the fiber-group and decreased in the control-group (p=0.002). The oat-fiber supplementation in the introduced form was well tolerated.
CONCLUSIONS: Use of oat-fiber allowed discontinuation of laxatives by 59% while improving body-weight and wellbeing of the seniors. Fiber supplementation is a safe and convenient alternative to laxatives in a geriatric hospital.

PMID 19214342  J Nutr Health Aging. 2009 Feb;13(2):136-9.
著者: S-M Hongisto, L Paajanen, M Saxelin, R Korpela
雑誌名: Eur J Clin Nutr. 2006 Mar;60(3):319-24. doi: 10.1038/sj.ejcn.1602317.
Abstract/Text OBJECTIVE: The aim of the study was to investigate the effects of fibre-rich rye bread and yoghurt containing Lactobacillus GG (LGG) on intestinal transit time and bowel function, and to test whether they have an interaction in cases of self-reported constipation.
DESIGN: The study was carried out as a two-by-two factorial design.
SETTING: Free-living subjects.
SUBJECTS: A total of 59 healthy women with self-reported constipation, recruited by advertisement.
INTERVENTIONS: After a baseline period, the subjects were randomized into four diet groups: (1) rye bread+LGG yoghurt, (2) rye bread, (3) LGG yoghurt, and (4) control. The 3-week dietary intervention was followed by a 3-week follow-up period. During each period, total intestinal transit time was measured and the subjects recorded faecal frequency and consistency, difficulty in defecation and gastrointestinal symptoms.
RESULTS: The rye bread shortened total intestinal transit time (mean difference, -0.7; CI(95), -1.1 to -0.2; P=0.007), increased faecal frequency (0.3; CI(95), 0.1 to 0.5; P=0.001), softened faeces (-0.3; CI(95), -0.4 to -0.2; P<0.001) and made defecation easier (-0.4; CI(95), -0.5 to -0.2; P<0.001), but also increased gastrointestinal symptoms (1.6; CI(95), 0.7 to 2.4; P<0.001) compared to the low-fibre toast consumed in the LGG and control groups. There were fewer symptoms in the rye bread+LGG group compared to the rye bread group (-1.3; CI(95), -2.4 to -0.2; P=0.027).
CONCLUSIONS: Fibre-rich rye bread can be recommended in the treatment of constipation, and the simultaneous consumption of LGG yoghurt relieves the adverse gastrointestinal effects associated with increased intake of fibre.
SPONSORSHIP: Valio Ltd, R&D, and Fazer Bakeries Ltd.

PMID 16251881  Eur J Clin Nutr. 2006 Mar;60(3):319-24. doi: 10.1038/sj・・・
著者: Lawrence Leung, Taylor Riutta, Jyoti Kotecha, Walter Rosser
雑誌名: J Am Board Fam Med. 2011 Jul-Aug;24(4):436-51. doi: 10.3122/jabfm.2011.04.100272.
Abstract/Text BACKGROUND: Chronic constipation is a common condition seen in family practice among the elderly and women. There is no consensus regarding its exact definition, and it may be interpreted differently by physicians and patients. Physicians prescribe various treatments, and patients often adopt different over-the-counter remedies. Chronic constipation is either caused by slow colonic transit or pelvic floor dysfunction, and treatment differs accordingly.
METHODS: To update our knowledge of chronic constipation and its etiology and best-evidence treatment, information was synthesized from articles published in PubMed, EMBASE, and Cochrane Database of Systematic Reviews. Levels of evidence and recommendations were made according to the Strength of Recommendation taxonomy.
RESULTS: The standard advice of increasing dietary fibers, fluids, and exercise for relieving chronic constipation will only benefit patients with true deficiency. Biofeedback works best for constipation caused by pelvic floor dysfunction. Pharmacological agents increase bulk or water content in the bowel lumen or aim to stimulate bowel movements. Novel classes of compounds have emerged for treating chronic constipation, with promising clinical trial data. Finally, the link between senna abuse and colon cancer remains unsupported.
CONCLUSIONS: Chronic constipation should be managed according to its etiology and guided by the best evidence-based treatment.

PMID 21737769  J Am Board Fam Med. 2011 Jul-Aug;24(4):436-51. doi: 10.・・・
著者: Charles A Ternent, Amir L Bastawrous, Nancy A Morin, C Neal Ellis, Neil H Hyman, W Donald Buie, Standards Practice Task Force of The American Society of Colon and Rectal Surgeons
雑誌名: Dis Colon Rectum. 2007 Dec;50(12):2013-22. doi: 10.1007/s10350-007-9000-y.
Abstract/Text
PMID 17665250  Dis Colon Rectum. 2007 Dec;50(12):2013-22. doi: 10.1007・・・
著者: Anna Chmielewska, Hania Szajewska
雑誌名: World J Gastroenterol. 2010 Jan 7;16(1):69-75.
Abstract/Text AIM: To systematically evaluate and update evidence on the efficacy and safety of probiotic supplementation for the treatment of constipation.
METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched in May 2009 for randomised controlled trials (RCTs) performed in paediatric or adult populations related to the study aim.
RESULTS: We included five RCTs with a total of 377 subjects (194 in the experimental group and 183 in the control group). The participants were adults (three RCTs, n = 266) and children (two RCTs, n = 111) with constipation. In adults, data suggests a favourable effect of treatment with Bifidobacterium lactis DN-173 010, Lactobacillus casei Shirota, and Escherichia coli Nissle 1917 on defecation frequency and stool consistency. In children, L. casei rhamnosus Lcr35, but not L. rhamnosus GG, showed a beneficial effect.
CONCLUSION: Until more data are available, we believe the use of probiotics for the treatment of constipation condition should be considered investigational.

PMID 20039451  World J Gastroenterol. 2010 Jan 7;16(1):69-75.
著者: John F Johanson, Dan Morton, Joseph Geenen, Ryuji Ueno
雑誌名: Am J Gastroenterol. 2008 Jan;103(1):170-7. doi: 10.1111/j.1572-0241.2007.01524.x. Epub 2007 Oct 4.
Abstract/Text OBJECTIVES: To assess the efficacy and safety of lubiprostone in adults with chronic constipation.
METHODS: This multicenter, parallel-group, double-blind controlled trial enrolled 242 patients with constipation and randomized them to receive oral lubiprostone 24 mcg or placebo twice daily for 4 wk. The primary efficacy end point was the number of spontaneous bowel movements (SBMs; those occurring without use of constipation relieving medications) after 1 wk of double-blind treatment. Other evaluations included SBMs at weeks 2, 3, and 4; bowel movement (BM) characteristics (i.e., consistency and straining); constipation severity; abdominal bloating/discomfort; global treatment effectiveness ratings; and safety assessments.
RESULTS: The 120 lubiprostone-treated patients reported a greater mean number of SBMs at week 1 compared with the 122 placebo-treated patients (5.69 vs 3.46, P= 0.0001), with a greater frequency of SBMs also reported at weeks 2, 3, and 4 (PCONCLUSIONS: In patients with chronic constipation, treatment with lubiprostone produces a BM in the majority of individuals within 24-48 h of initial dosing and improves the frequency as well as other characteristics associated with BMs with short-term (i.e., 4 wk) treatment. The most commonly reported adverse event was mild to moderate nausea, which resulted in treatment discontinuation in 5% of treated patients.

PMID 17916109  Am J Gastroenterol. 2008 Jan;103(1):170-7. doi: 10.1111・・・

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